SANBAG Claim

  • Please read instructions very carefully. 

    1.           Indicate the date this claim is being filed.

    2.           Provide name, address, work and home phone numbers and e-mail, if any,  of the claimant(s).

    3.           Provide Social Security Number of Claimant.

    4.           Provide date of birth of Claimant.

    5.           Indicate the date of incident.

    6.           How and when did the damage or loss occur? Provide in full detail the circumstances that led to the damage or loss and the time the damage or loss occurred.

    7.           Describe the nature and extent of the damage(s).  Be as specific as possible.

    8.           Provide name(s) of public employee or agency causing damage or loss, if known.

    9.           Provide dollar amount of claim - State the total amount you are claiming as a result of the alleged damage or loss.  Provide a breakdown of how the total amount was computed and provide copies of any bills, payments, receipts and cost estimates.

    10.        Provide the name and mailing address of the person to whom all official notices and other correspondence should be sent.  If the same as #2 above, write "same as in #2 above".

    11.        Signature- The claim must be signed, either by the claimant(s) or by an attorney authorized to represent the claimant.

    *Attach copies of all support documents to each completed SANBAG claim.

  • Date captured on form submission

Claimant(s) Information

Signatures

  • Date captured on form submission
  • Date captured on form submission